The UK and other wealthy countries have been accused of adopting a “new form of colonialism” in recruiting huge numbers of nurses from poorer nations to fill their own staffing gaps.
International nursing leaders said the trend was leading to worse patient care in developing nations, which were not properly compensated for the loss of experienced healthcare staff.
Howard Catton, the chief executive of the International Council of Nurses, said there was “real anger” among attenders at a meeting of nursing associations from across Africa in Rwanda this month.
He said: “The African nurse leaders said they were angry that high-income countries were using their economic power to take the nursing workforce they needed from poorer, more fragile countries.
“These wealthier countries were effectively creating a new form of long-term dependency that hinders the development of health systems in the source countries.”
They described it as “a new form of colonialism”, he said.
World Health Organization rules are supposed to prevent the poaching of staff from countries with vulnerable health systems. Recruitment from countries on the WHO “red list” should not take place without formal agreements.
Catton said, however, that even these often offered only a “veneer of ethical responsibility” and there was often little evidence of mutual benefit. He has previously called for a stronger global code of practice on international recruitment.
Dr Baboucarr Cham, the president of National Association of Gambia Nurses and Midwives, said: “It is causing a lot of issues in the Gambia, because our experienced nurses are leaving and going to Europe and America.
“Our main teaching hospital has around 300 registered nurse positions. Last year 53 left.”
Cham said the head of its midwifery unit told him she had lost 16 midwives, with staff shortages so severe that she had to leave her oversight role and return to the ward to deliver babies.
Recruiters target experienced nurses, Cham said, requiring at least two years of postgraduate experience in a large hospital.
The remaining staff “are caring for more people and then obviously you will get tired, you will get fatigued, and then patients will not receive quality care”.
In some rural facilities there are no registered nurses or midwives at all, Cham said, with severe consequences for local people: “They can lose their lives.”
He added: “We are not saying international recruitment should not happen. Obviously it is a fundamental human right to move to places where you can get better economic opportunities. But those recruiting should also give back to the country. If you recruit one nurse, you should [pay to] train two nurses.”
Remittances sent back by nurses overseas made a huge contribution to the Gambia’s development, he said, and some nurses do return with new skills and experience.
“But at the end of the day our health systems are vulnerable, they are weak, and not resilient, because we do not have enough manpower, and cannot retain the experienced ones,” Cham said.
The years since Covid have seen a notable increase in international healthcare recruitment. High levels of burnout in domestic workforces have created shortages just as more staff are needed to tackle post-pandemic backlogs. Developed countries also have larger ageing populations requiring more care.
In its 2019 election manifesto, the Conservative government promised to boost nurse numbers in England by 50,000 by 2024 – a target met only because of overseas recruitment.
Germany faces a shortfall of 150,000 nurses by 2025 and has launched overseas recruitment campaigns in several countries. Canada, Australia and the US also have hiring programmes, often carried out by regional authorities.
Recruiting countries point out higher levels of nursing unemployment in some of the countries they target but critics say this is generally because of a lack of money in health systems to pay salaries, rather than a lack of need.
In the UK, there are 9.2 nurses per 1,000 people, according to figures collated by the World Bank. For Germany it is 12.3.
In the Gambia, there are 0.9 nurses per 1,000 people.
Perpetual Ofori-Ampofo, president of the Ghana Registered Nurses and Midwives Association, said migration is “the right of the individual”.
She said: “You cannot stop them from moving abroad in terms of seeking better remuneration or of better conditions of service or aspiring for better or decent lives for themselves.”
But she said the fees associated with the official paperwork needed for a nurse to prove their qualifications to overseas regulators had recently gone up 445.5%, from 550 Ghanaian cedi (£33) to 3,000 (£180), suggesting government concern in a country with 3.5 nurses per 1,000 people.
“We see it as a way to curtail the movement of our nurses,” she said. The association says it would be better “for Ghana’s government to put in systems that will attract and retain nurses in Ghana, not to try to stop them”.
Overall nursing figures for Ghana, which do not always distinguish between degree-educated registered nurses and assistants with lower training levels, could mask the scale of the problem, she said.
“If you visit particular health facilities then you will see the reality of the situation – unit by unit, or department by department, they are feeling the pinch of their colleagues leaving and the burden of work that is left to those that are at their post.”
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